The Ducere Group
Board of Directors
Retreats, Camps, Classes
Partnerships and Collaboration
Forms and Policies
Take a Survey!
In partnership with
Gwinwood Conference Center
Camps and Classes Online Registration
Theatre - Performance
Theatre- Dinner (Cooking)
Camper Preferred Name
1st Parent or Guardian Name and Address
2nd Parent or Guardian Name and Address
Emergency Contact Name and Adress
Names / Phone numbers of other individuals who may pick your child up. Those not listed will not be able to pick up your child.
Please provide a brief description of your child (character traits, favorite activities, interest, hobbies, likes, and dislikes, etc.)
Please list any behaviors staff should be aware of. Please include any triggers which may cause the behavior.
Please offer any suggestions for handling behaviors.
If your child has any strong dislikes, please list them.
Please select all of the following that apply to your child:
Autism, Aspergers, PDD-NOS
Hearing or Visual Impaired
Seizures or Blackouts
Other Medical, Psychological, or Behavioral Concerns
Please explain any item checked above. If no items were checked, please list N/A for not applicable.
Please detail any medical condition checked above. If no items were checked, please list N/A for not applicable.
Please list any medications your child is taking that you feel we should know about. Please note, we only need to know about medications that may directly impact your child's life, such as an Epi-pen, or medications that may impact his or her ability to participate. Please note that we do not administer medications during the course of this program, other than in life saving instances. if your child has an Epi-pen, we must have a note signed by the doctor listing times and instances it should be administered and the manner in which to do so. If this does not apply to your child, please list N/A for not applicable.
You will be asked to comply with the following Release of Liability. Please indicate whether or not you have read and agree to the follow terms of service:
Yes. I agree with the Release of Liability and Hold Harmless agreement.
Release of Liability
I certify that I am the legal parent/guardian of __________________________. In consideration of acceptance into the above referenced program, I do hereby, for myself, my spouse, my children, my heirs, executors and assigns, release Gwinwood Christian Camp and Conference Center, The Ducere Group, and any other organization affiliated with events that take place as part of their camps and programs, and the officials, officers, agents, and employees and volunteers of
Gwinwood Christian Camp and Conference Center,
Ducere Group, and any other affiliate from liability for any harm, injury, or damage which I, or my minor children may suffer while participating in the above described programs. This includes all risks that are connected with this activity whether foreseen or unforeseen.
I agree to hold
Gwinwood Christian Camp and Conference Center, The
Ducere Group, and any other organization affiliated with events that take place as part of their camps and programs, and its agents, officials, employees and volunteers harmless from any damage to persons or property, resulting from the negligence and/or intentional act of myself or my children.
I assume the responsibility of my child or ward’s mental and physical fitness to participate in said activity, and agree to abide by all rules and requirements of the program.
I agree to have my photo or photo of my child or children, taken during classes to be used only for publicity purposes by
Gwinwood Christian Camp and Conference Center, T
he Ducere Group, and their programs.
I am of lawful age and legally competent to sign this agreement for and on behalf of the participant. I understand the terms and have signed this document as my own free act.
I, the undersigned, hereby expressly agree that this release and waiver is intended to be as broad and inclusive as permitted by the laws of the State of Washington and if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have fully informed myself of the contents of this release by reading it before I sign it. I realize that by signing this document I am giving up legal rights which I may be entitled to.
Signed By: __________________________________ Date: __________________
Program Cancellation Policy: No refunds given on programs cancelled less than 14 days prior to program date. For cancellations made more than 14 days prior to first date of program an 80% refund will be given. A 10% administrative fee will be charged for each program session change (cancellations are not considered session changes. This fee does not apply to program cancellations).
Gwinwood Christian Camp and Conference Center and
The Ducere Group reserve the rights to cancel any program. In the event that
Gwinwood Christian Camp and Conference Center or
The Ducere Group cancel a program, all program fees will be refunded in full.
Late Pickup Fee: After a 15 minute grace period, a late pickup fee of $10 for every 10 minutes will apply. This fee is applicable each program day.
Signed By: ____________________________________ Date: ______________________
Accommodation Request: The Ducere Group strives toward providing inclusive programs to all community members. People of all abilities are invited to consider registering for any recreational program The Ducere Group has to offer provided they meet the minimum eligibility requirements. To request an accommodation please allow 10 business days prior to the start of the course. Please call
to receive an accommodation request form.
Please scan and e-mail to firstname.lastname@example.org.
The Ducere Group
Board of Directors
Parent Advocacy Training
1 Small Change Summer Camp
Referral and Other Resources